Regular Purpose

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School District Information

School District Name

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School District Address

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City

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State

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Zip

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Phone

Required! Must be a valid phone number i.e.: 123-456-7890

Fax

Required! Must be a valid fax number i.e.: 123-456-7890

Losses

Has the District ever made claim against a surety or fidelity bond?

YesNo Required

If yes, please give a description of the situation and the amount of any payment.

Required

Investments

District Treasurer

Treasurer's Name (First, Middle, Last)

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Home Address (Street, PO Box, Apt.)

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City

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Zip

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Home Phone

Required

Business Phone

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What other positions does the treasurer hold within the district?:

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Has this person ever been charged with any kind of criminal offense?

YesNo Invalid Input

If yes, please describe.

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Request

Bond #

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Date of Last Audit

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Was audit free from criticism?

YesNo Invalid Input

Change Bond Amount From

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Change Bond Amount To

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Change District Treasurer From

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Change District Treasurer To

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Other Change

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Bond Amount

(Information from Annual Financial Report)

Receipts/Revenues (Current)

Valid characters: 0123456789 , $

Tax Anticipation Warrants/Notes

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Fund Balances

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Total of the above

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Bond Amount Requested

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Applicant Information

CERTIFICATION and SIGNATURE

The undersigned certifies that the information is true, correct and complete to the best of his/her knowledge.

Electronic Signature

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Please specify your email address.

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I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. Invalid Input

Security Code ◄

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Regular Purpose

School District Information

Losses

Investments

District Treasurer

Request

Bond Amount

Applicant Information

CERTIFICATION and SIGNATURE

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